Birth control

Abortion

Abortion is the termination of pregnancy less than 28 weeks after the last menstrual period. Until the eighth week of pregnancy the conceptus is called an embryo, and after that time a fetus. Abortion may be spontaneous (miscarriage) or induced, and induced abortions are legal in some circumstances in some countries and illegal in others. An incomplete abortion is one after which part of the conceptus remains in the uterus. It is associated with bleeding and the risk of infection.

Human reproduction is an imperfect process. Only one sperm is necessary for fertilization, yet the male’s ejaculate contains millions of sperm. As many as half of the eggs fertilized die within 10 days of fertilization without the woman even knowing she has conceived. As many as one-fifth of recognized pregnancies miscarry. Much of this massive wastage is associated with chromosomal and other abnormalities in the embryo.

Induced abortion has occurred throughout history and is known in almost all contemporary societies. A variety of herbs and potions have been used over the ages, and physical violence as a cause of abortion is mentioned in the Bible (Exodus 21:22). In the contemporary world tens of millions of abortions are performed annually. Some are deemed legal—i.e., carried out by qualified persons with proper supervision—and others illegal. Massage abortion is common in Southeast Asia. It is usually conducted by a traditional birth attendant who pounds the pregnant abdomen until uterine bleeding commences or pain stops the procedure. In the rest of the world a common method is to pass an object through the neck of the womb to dislodge the placenta. Abortions performed by unqualified persons can endanger the woman’s life. In Latin America, for example, approximately 1,000,000 women a year are admitted to hospitals suffering from incomplete abortions, mostly the result of illegal abortion.

Abortion and contraception have a complex relationship during the process of demographic change. A decline in the birth rate may reflect a rise in the number of abortions and the use of contraception. As the rate declines further, abortions peak (as in Japan in the 1950s and 1960s), but, if contraceptive services are readily available, then the number of abortions falls as the number of conceptions falls. If, however, contraceptive services are not readily available (as in the Soviet Union), then the number of abortions remains high.

The commonest technique of inducing legal abortion is vacuum aspiration of the uterine cavity. When completed before the 12th week of pregnancy the procedure is brief and can be done without general anesthesia. It has proved to be remarkably safe for the woman, with a death rate of less than one in 100,000 operations. Scraping (curettage) of the uterus is an older surgical procedure. It is less satisfactory than vacuum aspiration early in pregnancy but can be more easily used after 12 weeks. Late abortions can also be performed by chemical means (the introduction of prostaglandins) or by the injection of urea or salt into the space around the embryo.

Family planning services

National family planning movements have emphasized the right of the individual to determine family size as well as the contribution family planning can make to national and global population problems. Some methods of birth control, such as coitus interruptus and, in extreme cases, abortion, may involve no person other than the individual or couple. But most methods require manufacture, distribution, promotion, counselling, and in some cases financial subsidy.

The retail trade in contraceptives has been a major element in the spread of contraception and remains important in the developing world. In particular, social marketing programs, which adjust prices to people’s needs, have allowed governments to make contraceptives available to large numbers of people quickly and at affordable cost. Private doctors may advise patients about the use of birth control on a confidential basis and may charge a fee.

The first altruistic attempts to offer direct family planning services began with private, pioneering groups and often aroused strong opposition. The work of Sanger and Stopes reached only a small fraction of the millions of couples who in the 1920s and ’30s lived in a world irrevocably altered by World War I, crushed by economic depression, and striving for the then lowest birth rates in history. In 1921 Sanger founded the American Birth Control League, which in 1942 became the Planned Parenthood Federation of America. In Britain the Society for the Provision of Birth Control Clinics was to evolve into the Family Planning Association. As early as 1881 the British Malthusian League had brought together individuals from 40 nations to discuss birth control, and five genuinely international meetings had taken place by 1930. A conference was held in Sweden in 1946. The first birth control clinic in India opened in 1930, and in 1952 in Bombay, Margaret Sanger took the first steps toward creating what became the International Planned Parenthood Federation (IPPF).

The modern era in international family planning opened in the second half of the 1960s when governments, beginning with Sweden, gave money to support the worldwide work of the IPPF. William Draper lobbied with particular effectiveness in the United States to build up the IPPF and to put together the United Nations Fund for Population Activities (UNFPA), established in 1969. For several years the U.S. Agency for International Development helped to support the IPPF and the UNFPA. The United Nations held international conferences on population in Bucharest in 1974 and Mexico City in 1984.